Complaint·February 10, 2026

Allegation: Staff prevented resident from attending day program services. It was alleged that staff prevented a resident from attending day program services. This investigation consisted of interviews with residents, facility staff and the reporting party. On 1/13/2026, LPA Hughes conducted a visit to the facility. LPA spoke with 2 out of 5 residents who stated that they do not attend day program. Additional interview with resident (R1) stated that facility staff allow them to attend day program daily, stating staff assist them with preparing for day program. Interview with the facility administrator reported that the resident (R1) enjoys day program, and facility staff have never prevented the resident from attending day program services. LPA attempted to speak with the reporting party but could not obtain any further details. There was not enough evidence present to corroborate this allegation; therefore the allegation is unsubstantiated. Allegation: Staff did not dispense medication to resident as prescribed. It was alleged that staff did not dispense medication to a resident as prescribed. This investigation consisted of interviews with residents, facility staff, and a review of records. On 1/13/2026, LPA Hughes conducted a visit to the facility and spoke with facility staff (S2) who stated that they primarily dispense resident’s medications, stating that residents are given medications timely as prescribed. Interview with 3 out of 5 residents stated that they receive their medications timely as prescribed. Review of the Medication Administration Record (MAR) and Centrally Stored Medication Administration Record (CSMDR) for resident (R1) and (R2) indicated no discrepancies in medications not being administered as prescribed. Allegation: Staff did not communicate in a timely manner to coordinate resident’s care and Staff did not ensure resident received timely medical care. It was alleged that staff did not communicate in a timely manner to coordinate resident’s care with physician’s appointments for body rashes. This investigation consisted of interviews with facility staff, residents, the reporting party, and records review. On 1/13/2026 LPA Hughes conducted a visit to the facility and spoke with the facility administrator who reported that the resident has been seen by their primary care physician regarding a body rash initially on 10/2025. The administrator stated that the resident was medically cleared on 10/16/2025. The resident was seen again by their primary care physician on 01/2026 regarding a body rash and cleared on 1/30/2026. Interview with resident R1 stated that they suffer from itching due to rashes on their body. Resident (R1) stated that the facility administrator assists the resident with scheduling and transportation to physician’s appointments. Continuation 9099-C Additional interview with the reporting party reported that resident (R1) left the facility unassisted and was found at a gas station, additional information regarding the incident was not provided as the RP did not provide further details regarding the incident. LPA conducted a review of the LIC 602 Physician's report for resident (R1) it was reported that resident (R1) is unable to leave the facility unassisted. However, staff reported that resident R1 was followed and monitored by facility staff at the time of the elopement. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegation are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violation occurred. During an additional interview, the reporting party stated that the resident was suspected of having body lice twice, and at their request, resident (R1) was evaluated by a physician and were cleared of any indication of body lice. The reporting party further stated that the resident was observed to have a body rash only, and the facility did send medical clearance for the resident. Review of resident (R1) records indicated the resident was evaluated by a physician and medically cleared for two separate instances. There is not enough evidence present to corroborate this allegation. The investigation revealed the preponderance of evidence standards have not been met; therefore, the above allegations are found to be UNSUBSTANTIATED . A finding that the complaint allegations are UNSUBSTANTIATED means that although the allegations may have happened or are valid, there is not a preponderance of the evidence to prove that the alleged violations occurred.